A History of #HealthReform

final hrKurt A. Yaeger, MD (left)
Neurosurgical Resident, Mt. Sinai Hospital
New York, NY

Clemens M. Schirmer, MD, PhD, FAANS, FAHA (right)
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger Health System
Wilkes Barre, PA

hc3 fianl 30In March and April, Neurosurgery Blog considered various aspects of the Affordable Care Act (ACA). Clearly, the signs are pointing towards change, and even though the first major Republican proposal, the American Health Care Act (AHCA), barely squeaked through the House of Representatives, it’s certainly not going to be the last word on health reform; thus it is worth focusing on the fundamentals. Looking back, when fashioning major U.S. health care reform in the early days of President Barack Obama’s first administration in 2008, policymakers maintained one overarching principle: to improve access to quality and affordable health care. In a 2008 article published in the journal Health Affairs, Donald Berwick, MD, MPP, FRCP, and coauthors posited that “improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” The costs of such a system were to be driven down by increasing the number of people in the insurance market through an individual mandate, enhancing the efficiency of health care, and focusing on preventive care and chronic disease. Medical professionals and health policymakers recognized that the “proliferation of high-end health care… led to an increased demand on health care, resulting in cost escalation,” and this “runaway overutilization of [U.S.] health care was unsustainable.”

Reform was inevitable, but it took a U.S. political overhaul in the 2008 presidential election to stimulate definitive action. Even before the signing of the ACA in 2010, the reform was met with controversy from all political lines. Throughout this period, organized neurosurgery has been at the forefront of policy development. The philosophy of expanding access to quality, cost-effective neurosurgical care has remained constant and will continue to drive legislative efforts as the new health care reform proposals evolve.

Before Contemporary Health Reform 

Following its introduction in 1965, the U.S. Medicare system has adopted several critical revisions, including the addition of payments to managed care plans in 1997 (Medicare Part C) and prescription drug coverage in 2006 (Medicare part D). For physicians, a monumental change was introduced in 1992 with the development of a resource-based relative value scale (RBRVS), which based payments on the resource costs associated with a particular service. In 1997, the sustainable growth rate (SGR) formula was introduced to limit physician spending and ensure that the annual increase in health care spending per Medicare beneficiary did not exceed the growth in Gross Domestic Product (GDP). Since this formula was based entirely on estimated changes in fees for physicians’ services, it was inherently flawed, and eventually required compensatory cuts in physician payments. In the years following the introduction of this fee-for-service model, U.S. health care spending increased along an unsustainable trajectory. Barack Obama was elected as president in 2008 in part for his pledge to revamp the U.S. health care sector and provide universal health care coverage to U.S. citizens.

Transition to Reform

With the signing of the ACA on March 23, 2010, the U.S. health care system ushered in an era of accountability for providers to deliver quality and efficient care. With an emphasis on pay-for- performance, rather than on a fee-for-service basis, many physicians, including subspecialty providers, were required to begin adopting new cost-effective practice models. Since the inception of the ACA, organized neurosurgery has been highly active in the dynamic shaping of U.S. health care reform, with the goal of improving access to quality neurosurgical care across the country. Marc A. Vanefsky, MD, FAANS, then-president of the California Association of Neurological Surgeons, stated “it is no longer enough to say ‘I am just the neurosurgeon’… Organized Neurosurgery has a responsibility to continue to influence healthcare legislation to make sure that we can continue to provide the highest quality care to our patients.”

In April 2010, organized neurosurgery published its perspective on the recently approved ACA. The list of reform priorities included covering the uninsured, lowering health care costs, preventing a single payer system, ensuring direct access to subspecialty care, as well as limiting the role of government in residency training. Importantly, neurosurgery also commented that the provision of quality should be determined by the profession. This commentary also addressed concerns about the establishment of the Independent Payment Advisory Board (IPAB), a politically appointed committee that would have vast authority to determine Medicare payment rates. This early perspective about the ACA by members of organized neurosurgery cited few elements of “good news” about the ACA — primarily that it was not based on a single-payer model. The list of “bad news” was considerable; an overarching concern was focused on the expansion of Medicaid, the potential future reimbursement battle with primary care physicians, and the undervaluing of the physician fee schedule with regards to subspecialty care. AANS and CNS also believed that there was not enough emphasis on medical liability reform, obviously a critical factor in a neurosurgeon’s practice.

Neurosurgery’s concerns were echoed throughout the medical profession and beyond, and the health care law was first challenged in Florida in January 2011. Elements of the law were ruled unconstitutional, specifically the individual mandate and Medicaid expansion, and twenty-five other states soon followed suit. In November 2011, the challenge was brought to the U.S. Supreme Court in the case National Federation of Independent Business v. Sebelius, and on June 28, 2012, the Court ruled that the mandate to purchase health insurance was a valid exercise of Congress’s power under the Taxing Clause.

Subsequently, the constitutionality of the ACA’s insurance premium tax credits for individuals obtaining insurance through federal exchange plans was challenged in the U.S. Supreme Court in the case of King v. Burwell. On June 25, 2015, the case was affirmed by a vote of 6-3, allowing such federal subsidies. In light of this resolution, the AANS and CNS called upon Congress to “increase consumer choice beyond the current government mandated plans, by allowing individuals to choose plans such as health savings accounts.”

Present Reform Landscape

The ACA has been a politically dichotomous issue throughout its existence. As such, on Nov. 8, 2016, health care reform was launched into uncertainty with the presidential election of Donald Trump. President Trump’s first executive order, signed on inauguration day, was entitled the “Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal.” Less than a week later, Barack Obama cautioned the new administration’s “Repeal then Replace” policy in an editorial in the New England Journal of Medicine. “What the past 8 years have taught us,” he states, “is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people. That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless. Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.”

Even as the health reform debates continues, what remains constant is the effort of organized neurosurgery to help shape the course of health care reform. The recently published AANS and CNS 2017 Legislative and Regulatory Agenda advocates for policy change on behalf of neurosurgeons and their patients throughout the country. Importantly, there remains a consistent support for “expanding the access to affordable health insurance coverage for all Americans.” This philosophy should remain at the forefront of all future endeavors in this dynamic health care reform landscape.

Posted in Access to Care, Antitrust, Coding and Reimbursement, Congress, GME, Health, Health Reform, Healthcare Costs, IPAB, MACRA, MedEd, Medical Liability, Medicare, Quality Improvement, SGR | Tagged , , , , , , , , , |

60 is the New 40: Did You Ask Your Spine About That?

benzilGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Chair, AANS/CNS Communications and Public Relations Committee
Mount Kismo Medical Group
Columbia University Medical Center
Mt Kisco, New York 

Aging Population

Medicine is facing a real crisis. In fact, this monumental challenge hasn’t even attracted much attention of the media. Some attention has been given to costs associated with this demographic. However, across the country, neurosurgeons are coping with the escalating problems associated with the aging spine. Consider the following critical statistics — in the year 2020.

  • There will be at least 75 million Americans over the age of 65;
  • 14 million will have osteoporosis;
  • Nearly 30 million have low bone mass;
  • Patients over the age of 65 consume one-half of all health care dollars (over $80 billion) and one-half of all hospital days;
  • Osteoporosis alone costs more than $20 billion annually;
  • The typical age of a patient having spine surgery increased by more than five years (48.8-54.2) in the decade 1998-2008 and continues to rise dramatically; and
  • Those who reach the age of 65 are likely to live nearly 20 more years.

As life expectancy has increased, there is the concomitant expectation of being able to lead an active and vibrant life. Too often the aging spine has different ideas.

The Aging Spine

spine 21Is it just bad luck or do our spinal columns age badly? Why are our spines so vulnerable? Our spinal columns serve two incredibly important functions. The first is providing protection for our spinal cord and nerves. To do this our spinal column must be very strong (think about a knight’s plated armor). However, the second function of our spine is to provide the primary support for all of our mobile activity, including the need for flexibility (think of all the bending, twisting and reaching we do just to get dressed). In order to serve both of these crucial tasks everyday or our lives, the spine is made up of a series of bones that require precise synchrony and connectivity, much like a complex set of gears in a machine. Unfortunately, this also means there are many small parts (joints, ligaments, tendons and muscles) that can show the effects of wear and tear over time. Osteoporosis serves to significantly aggravate this entire process in many ways leading to a downward spiral for the individual.


What is osteoporosis?

  • A condition of skeletal fragility characterized by compromised bone strength predisposing to an increased risk of fracture.

Who gets osteoporosis?

  • Everyone is at risk! While it is a disease of aging, it can strike at any age. Women have a much higher risk than men.

How is osteoporosis diagnosed?

  • Screening should routine be performed using a simple test called a Bone Density Test (called a DXA scan).

Can osteoporosis be prevented?

  • While osteoporosis may not be entirely preventable, there are definitely things that can reduce the risk of developing osteoporosis or sustaining the worst consequences (debilitating fractures) resulting from this disease.


Osteoporosis and Neurosurgery

Recently, a thin and active 92-year-old man came to my office with a primary complaint of having back pain that interfered with his three time a week tennis game. He was in remarkably good health, on no medication other than a baby aspirin, with no prior surgeries. Until recently, he had regularly walked several miles, played a vigorous game of tennis, and regularly attended a variety of cultural events in New York City. However, for the last six weeks, he experienced debilitating pain in his back and both legs whenever he played tennis more than 10 minutes or walked more than one block. His life, as he knew and loved it, had been thoroughly disrupted. Evaluating his spine revealed osteoporosis with marked degeneration resulting in a significant curvature (called scoliosis) and narrowing of the spinal canal (called stenosis) such that his nerves were being compressed. As a neurosurgeon, my challenge was to try and design an intervention that would help restore function and quality of life with limited risk.

Accepting the Challenge

Neurosurgeons across the country are addressing this new challenge in a variety of ways:

  • We are carefully choosing patients who can benefit from surgical intervention to restore function and quality of life, even in the face of advancing age;
  • We are working with our medical colleagues to identify at risk patients and get early intervention;
  • We are providing professional and patient education programs;
  • We are doing research to help better understand how to limit the risks associated with surgery when it is needed;
  • We are using registries and other data to measure care delivery and outcomes in a meaningful way; and
  • We are collaborating with our anesthesia colleagues in pre- and post-operative management of this higher risk population.

May is National Osteoporosis Month, the perfect opportunity to highlight the importance of our spines and the downward spiral that osteoporosis causes. The aging spine poses a real challenge for all of medicine right now, but neurosurgeons will continue to lead the way in finding solutions that help our patients live long and active lives.


Posted in Guest Post, Health, Healthcare Costs, Pain, Spine Care | Tagged , , , , , , , , , , , , |

CNS Spotlight: Congress Quarterly Presents the CNS 2016 Annual Report

elad 4Guest post from Elad I. Levy, MD
Editor, Congress Quarterly

Congress Quarterly (cnsq) is the official newsmagazine of the Congress of Neurological Surgeons (CNS), written by and for neurosurgeons to explore topics of unique value and interest to our specialty, from neurosurgeons as artists to helping with U.S. tragedies.

In today’s post we wanted to highlight the 2016 CNS Annual Report issue of the Congress Quarterly which harnesses the synergies the CNS creates with its valued members. As the title, “Better Together,” suggests, advancement, innovation, and educational excellence is achieved through the tremendous combined volunteerism and feedback of the membership around the globe. In 2016, we worked tirelessly and are happy to report some exciting highlights:

  • cg2NEUROSURGERY® Publications continues to thrive under the direction of Editor-in-Chief, Nelson M. Oyesiku, MD, PhD. Our flagship journal, Neurosurgery, received its highest Impact Factor to date in 2016, and Operative Neurosurgery expanded to a bimonthly publication with an entirely independent editorial review board. In addition, our members now can enjoy The Surgeon’s Armamentarium, a new digital search function that puts the vast resources of the journals at your fingertips.
  • The CNS continues its legacy of innovative educational programs for members with updated live courses and the Annual Meeting, which remains the only neurosurgical meeting to showcase live surgical cases to allow real-time learning. With audience participation and moderators, this unique education platform showcases technical nuances and decision-making analyses. Online education experienced dramatic growth as it helped to guide CNS membership into a dynamic, increasingly electronic future with online webinars, courses, and expanded SANS modules.
  • The CNS continues to be fortunate to have one of the most effective teams in Washington, DC. We made significant progress on tough issues in 2016, such as helping to guide the Medicare Access and CHIP Reauthorization Act (MACRA), abolishing the Independent Payment Advisory Board (IPAB), and advocating to provide additional funding for graduate medical education (GME).

Overall, 2016 provided exciting new avenues of growth and advancement. We hope the full report is of interest. The CNS is committed to meeting the evolving needs of neurosurgery and advance the specialty over the course of 2017.

Posted in CNS Spotlight | Tagged , , , , , , , |